HIV/AIDS: Trends in the Middle East and North Africa Region

HIGHLIGHTS

• New HIV infections have been on the rise in the Middle East and North Africa (MENA) region in recent years.
• There is substantial heterogeneity in HIV epidemic dynamics across MENA, and different risk contexts are present throughout the region.
• Overall, the major route of infection in the MENA region seems to be sexual transmission, but a range of challenges limit interventions to determine the actual sexual trends.
• Despite unfavorable conditions, many countries in the region have put significant efforts into scaling up their response to this growing epidemic.

OBJECTIVES:

To give an overview of the HIV epidemic in the Middle East and North Africa (MENA) region.

METHODS:

Articles on the MENA region were reviewed.

RESULTS:

The MENA region comprises a geographically defined group of countries including both high-income, well-developed nations and low- and middle-income countries. While the annual number of new HIV infections in Sub-Saharan Africa has declined by 33% since 2005, new HIV infections in the MENA region have increased by 31% since 2001, which is the highest increase among all regions in the world. Moreover, the number of AIDS-related deaths in 2013 was estimated to be 15000, representing a 66% increase since 2005. However, the current prevalence of 0.1% is still among the lowest rates globally. There is substantial heterogeneity in HIV epidemic dynamics across MENA, and different risk contexts are present throughout the region. Despite unfavorable conditions, many countries in the region have put significant effort into scaling up their response to this growing epidemic, while in others the response to HIV is proving slower due to denial, stigma, and reluctance to address sensitive issues.

CONCLUSIONS:

The HIV epidemic in the MENA region is still at a controllable level, and this opportunity should not be missed...

Overall, the major route of infection in the MENA region seems to be sexual transmission. In 2011, heterosexual sex was the most common reported mode of HIV transmission among men in Tunisia (44.4%), UAE (50.0%), Syria (54.5%), Jordan (66.7%), Morocco (81.9%), Kuwait (100%), and Palestine (100%).⁸However, a range of challenges including (but not limited to) those listed below, limit interventions to determine the actual sexual trends, making the current data unreliable.

• The prevalence data available for KPs are principally derived from passive surveillance data, which tend to underestimate the role of high-risk behaviors because of individuals’ fear of disclosure.⁹
• There is intense HIV-related stigma and discrimination in the region, which is likely a major challenge for behavioral research.¹⁰
• Same-sex conduct is illegal in 76 countries, 19 of which are in MENA. In seven countries, including Iran, Saudi Arabia, Somalia, Sudan, and Yemen, homosexual acts are subject to the death penalty in some cases.⁶ Other countries, including Algeria, Egypt, Iraq, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, the Syrian Arab Republic, Tunisia, and the UAE, either criminalize adult consensual same-sex sexual conduct or have criminally prosecuted lesbian, gay, bisexual, and transgender people under other laws on the basis of their sexual orientation and gender identity.⁶
• Cultural and religious norms disapproving and penalizing sex between men may contribute to the nondisclosure of homosexual orientation and/or sexual conduct.¹¹

Other challenges that may be related to HIV surveillance in the MENA countries include infrequent surveillance of populations most at risk of HIV infection, lack of behavioral data, over-reliance on HIV case reporting and facility-based surveillance, and limited quality of HIV surveillance in general.¹²

  

Full article at:   http://goo.gl/e48IMn

By:  Gökengin D1, Doroudi F2, Tohme J3, Collins B4, Madani N5.

¹Department of Clinical Microbiology and Infectious Diseases, Medical Faculty, Ege University, Bornova, Izmir, Turkey. Electronic address: deniz.gokengin@ege.edu.tr.

²UNAIDS - The Joint United Nations Programme on HIV/AIDS (UNAIDS), Islamic Republic of Iran. Electronic address: DoroudiF@unaids.org.

³M-Coalition, Yazbeck Center, Achrafieh, Beirut, Lebanon. Electronic address: jtohme@afemena.org.

⁴International HIV Partnerships, London, UK. Electronic address: bc@ihp.hiv.

⁵Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: navid_madani@dfci.harvard.edu.

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HIV Seropositivity & Sexuality: Cessation of Sexual Relations among Men & Women Living with HIV in Five Countries

The sexuality of people living with HIV (PLHIV) is a key issue in the fight against HIV, as it influences both the dynamic of the epidemic and the quality of life of PLHIV. 

The present study examined the factors associated with cessation of sexual relations after HIV diagnosis among men and women in five countries: Mali, Morocco, Democratic Republic of the Congo, Romania and Ecuador. A community-based cross-sectional study was implemented by a mixed consortium [researchers/community-based organizations (CBO)]. Trained CBO members interviewed 1500 PLHIV in contact with CBOs using a 125-item questionnaire. 

A weighted multivariate logistic regression and a separate gender analysis were performed. Among the 1413 participants, 471 (33%) declared that they stopped having sexual relations after their HIV diagnosis, including 318 women (42%) and 153 men (23%) (p < .001). 

Concerning women, variables associated with the cessation of sexual relations in the final multivariate model were mainly related with relational factors and the possibility of getting social support (e.g., needing help to disclose HIV serostatus, feeling lonely every day, not finding support in CBOs, not being in a couple). 

Men's sexual activity was more associated with their representations and their perception of the infection (e.g., thinking they will have their HIV infection for the rest of their life, perceiving the HIV infection as a mystery, perceiving the infection as serious). 

Furthermore, the following variables were associated with both men and women sexual behaviours: being older, having suffered from serious social consequences after serostatus disclosure and not being able to regularly discuss about HIV with their steady partner. 

Results suggested clear differences between men and women regarding cessation of sexual relations and highlighted the importance of implementing gender-based tailored interventions that promote safe and satisfying sexuality, as it is known to have a positive impact on the overall well-being of PLHIV.

Purchase full article at:   http://goo.gl/XgYIvD

By:  Bernier A1, Lefèvre M1, Henry E1, Verdes L2, Acosta ME3, Benmoussa A4, Mukumbi H5, Cissé M6, Otis J7, Préau M8.

• 1 Coalition Internationale Sida , Pantin , France.
• 2 ARAS , Bucharest , Romania.
• 3 Kimirina , Quito , Ecuador.
• 4 ALCS , Casablanca , Morocco.
• 5 ACS/AMO Congo , Kinshasa , Democratic Republic of the Congo.
• 6 ARCAD-SIDA , Bamako , Mali.
• 7 CReCES, Université du Québec à Montréal , Montréal , Canada.
• 8 Social Psychology Research Group , Institute of Psychology, University of Lyon 2 , Bron , France.
• AIDS Care. 2016 Feb 28:1-6.  

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Assessing Reactive and Proactive Aggression in Detained Adolescents Outside of a Research Context

The Reactive Proactive Aggression Questionnaire (RPQ) is a self-report tool for assessing reactive aggression (RA) and proactive aggression (PA). This study contributes to the literature by testing the psychometric properties of the RPQ across detained boys from various ethnicities whilst using data that were gathered during clinical assessments. The factorial, convergent, and criterion validity, and the internal consistency of the RPQ scores received strong support in the total sample and across four ethnicity groups. Also, three groups of boys were identified, with the group including boys with high levels of both RA and PA including the most severe boys in terms of anger, delinquency, alcohol/drug use, and psychopathic traits, and having the highest prevalence rate of conduct disorder and substance use disorder. Together, these findings suggest that the RPQ may hold promise for assessing RA and PA in detained boys, even when confidentiality and anonymity of the information is not guaranteed.

… Results from confirmatory factor analyses (CFA) supported the two-factor structure over the one-factor structure of the RPQ, and showed that a significant distinction can be made between reactive aggression and proactive aggression in detained adolescent males. Specifically, all model fit indices were indicative of an acceptable or good model fit in the total sample and in youths from various ethnicities, except for the χ²/df ratio for the total sample. However, with increasing sample size and a constant number of degrees of freedom, the χ² value increases, and theχ²/df ratio, therefore, may suggest to reject a plausible model [38]. Because the χ²/df ratio was below the cut-off value in three subgroups and because all the other fit indices supported the two-factor model of the RPQ, this model can be considered to be acceptable in the total sample as well.

Our findings also provide support for the convergent validity of the RPQ scores. At the zero-order level, RPQ total, RA and PA scores, were positively related to other indices of aggressive behavior and features of anger-irritability. Also, after controlling for the PA score, only the RA score remained significantly related to anger and irritability, but was no longer related to aggressive CD symptoms. These results support the view that reactive, but not proactive aggression, is often accompanied with anger and a loss of impulse control [4,5]. Although some of the aggressive CD symptoms can occur as an uncontrolled response to frustration or anger (e.g., forcing someone into sexual activity, initiating fights, using a weapon that can cause serious physical harm), the RA score was never significantly related to aggressive CD symptoms after controlling for the PA score. Yet, after controlling for the RA score, the PA score remained significantly related to aggressive CD symptoms (Table 3) in the total sample and Dutch and Moroccan boys. This suggests that the aggression displayed by detained youths with a CD diagnosis is likely to be premeditated and planned, a notion that is supported by the finding that only the PA score was positively related to aggressive conduct disorder (Tables 4, ​,55).

The results also supported the criterion validity of the RPQ score in detained male youths. As hypothesized, only the RA score was positively related to depressive feelings, anxiety, and suicide ideation after controlling for the other RPQ scale score. Although there were no clear expectations about the relationship between the RPQ and social problems, the RA score was positively associated with this outcome in the total sample and some ethnicity groups. Overall, our findings are in accordance with recent work, including studies that scrutinized relations with suicide risk, social problems and peer rejection [41, 42], and support the claim that reactive aggression is an indicator of overall poor psychosocial adjustment [13]. However, the results do not support the suggestion that reactive aggression is primarily related to low prosocial behavior, and that proactive aggression has little or no association with prosocial behavior independent of reactive aggression [13]. In contrast, the present study showed that only the PA score was significantly negatively related to prosocial behavior after controlling for the RA score. Given that few studies addressed the relationship between self-reported reactive and proactive aggression and prosocial behavior, future studies are warranted. The finding that a higher PA score was associated with a lower level of prosocial behavior, nevertheless, corresponds with the finding that only PA was positively related to self-reported offenses (Tables 4, ​,55)…

Full article at:   http://goo.gl/O5mjWE

By:  Olivier F. Colins

Department of Child and Adolescent Psychiatry, Curium-Leiden University Medical Center, Endegeesterstraatweg 27, 2342 AK Oegstgeest, The Netherlands

Academic Workplace Forensic Care for Youth (Academische Werkplaats Forensische Zorg voor Jeugd), Zutphen, The Netherlands

Olivier F. Colins, Email: ln.muiruc@sniloc.o.

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Hepatitis C Virus and HIV Infections among People Who Inject Drugs in the Middle East and North Africa: A Neglected Public Health Burden?

People who inject drugs (PWID) are a key population at risk of hepatitis C virus (HCV) and HIV infections. Globally, 63% of PWID are HCV infected [1, 2] and 19% are HIV infected [2], leading to an estimated 10 million and 3 million HCV- and HIV-infected PWID, respectively [1–3]. The Middle East and North Africa (MENA), a region comprising 23 countries from Morocco in the West to Pakistan in the East, is at the centre of major drug production and trade, creating a context of vulnerability to injecting drug use [4]. PWID in MENA are a large, mostly young and stigmatized population experiencing a substantial HCV and HIV burden, with potential for even further HIV epidemic growth. Yet, they lack access to comprehensive and confidential HCV and HIV testing, prevention and treatment services.

Below:  Median HCV prevalence among people who inject drugs in the Middle East and North Africa as per available studies [6]. Error bars represent the lower and upper bounds of the interquartile range if more than one data point was available per country.

Full article at:   http://goo.gl/qK72Up

By:   Ghina R Mumtaz,§,1,2 Helen A Weiss,3 and Laith J Abu-Raddad1,4

¹Infectious Disease Epidemiology Group, Weill Cornell Medical College – Qatar, Cornell University, Qatar Foundation – Education City, Doha, Qatar

²Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom

³MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom

⁴Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, NY, USA

^§Corresponding author: Ghina R Mumtaz, Infectious Disease Epidemiology Group, Weill Cornell Medical College – Qatar, Cornell University, Qatar Foundation – Education City, P.O. Box 24144, Doha, Qatar. Tel: +(974) 4492 8406. Fax: +(974) 4492 8422. (Email:ude.llenroc.dem-rataq@6002mig) 

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Human Papillomavirus Genotypes among Women With or Without HIV Infection: An Epidemiological Study of Moroccan Women from the Souss Area

Background

Data on Human PapillomaVirus (HPV) infection are scarce in Morocco. The objective of the study was to determine the prevalence of HPV and cervical cytology abnormalities in women from the Souss area, Morocco.

Methods

Two hundred and thirty two women who attended the Hassan II hospital (Agadir, Morocco) were recruited in this study. Socio-economic data, sexual activity, reproductive life, history of Pap smear, smoking and HIV status were recorded. Cervical samples were taken using an Ayre spatula. Cytology was reported using the Bethesda system. HPVs were first detected by MY09/11 consensus PCR and then genotyped with INNO-LiPA^® assay. Data were analyzed using the logistic regression model.

Results

The median age of women was 42 years (18–76 years). HIV prevalence was 36.2 %. Any HPV type prevalence was 23.7 % in the study population, lower in HIV-negative women (13.3 %) than in HIV-positive women (39.3 %). HPV16 was the most prevalent type (6.5 %), followed by HPV53 and HPV74 (3.4 % each). Most women had normal cervical smears (82 %), the remaining were diagnosed with LGSIL (13 %) and HGSIL (5 %). HPV was detected in 17.4 % of normal smears, 43.4 % of LGSIL and 75 % of HGSIL. HIV status was the most powerful predictor of high risk (hr) and probable hr (phr) HPV infection (odds ratio 4.16, 95 % confidence interval 1.87–9.24, p = 0.0005) followed by abnormal cytology (OR 3.98, 95 % CI 1.39–11.40, p = 0.01), independently of socio-demographic and behavioral risk factors.

Conclusions

In a Moroccan hospital based-population of the Souss area, HPV infections are frequently detected. In addition, high prevalence of hr and phrHPVs and precancerous lesions among HIV-positive women is likely associated with an increased risk of cervical cancer. This highlights the need for HPV and cervical cancer prevention campaigns in Morocco.

Below:  Distribution of HPV genotypes among the 33 HIV+/HPV+ Moroccan women from the Souss area, Morocco. The prevalence of HPV genotypes was calculated by dividing the number of women harboring specific HPV genotype as a single infection (black bars) or multiple infections (grey bars) by the number of HIV+/HPV+ women

Full article at:   http://goo.gl/AyKLVf

By:   Essaada Belglaiaa, Hicham Elannaz, Bouchra Mouaouya, Mohamed Aksim, Mariette Mercier, Jean-Luc Prétet, Said Chouham, and Christiane Mougin

Laboratoire de Biologie Cellulaire et Génétique Moléculaire, Faculté des Sciences, Université Ibn Zohr, BP8106, Agadir, 80000 Maroc

EA 3181, Lab Ex LipSTIC ANR-11-LABX-0021, Université de Franche-Comté UBFC, F-25000 Besançon, France

Laboratoire de biologie moléculaire, 5ème Hôpital Militaire, Guelmim, Maroc

Service d’anatomopathologie, Hôpital Hassan II, Agadir, Maroc

Laboratoire de Biologie Cellulaire et Moléculaire, Inserm CIC 1431, CHRU Jean Minjoz, Boulevard Fleming, 25000 Besançon, France

Essaada Belglaiaa, Email: moc.liamg@aaialglebadaasse.

 

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Perception & Satisfaction of Cervical Cancer Screening by Visual Inspection with Acetic Acid (VIA) at Meknes-Tafilalet Region, Morocco

Background

This study aims to explore the perception and satisfaction of cervical cancer screening by Visual Inspection with Acetic acid (VIA) in Meknes-Tafilalet Region among target women.

Methods

A cross-sectional study was conducted using face-to-face interviews with women, routinely attending health centers, who met the inclusion criteria. Descriptive analysis was undertaken to report data.

Results

A total of 324 women were included in the study. Results revealed low awareness about cervical cancer (19.6 %) and a very high acceptability of VIA screening (94.5 %). Of the 306 women screened, 99 % stated that they would recommend the VIA testing to their friends and female relatives. All those women who were screened negative expressed their intent to repeat the test every three years. Those found VIA positive affirmed they would perform confirmatory explorations. The majority (96.3 %) of the women believed that screening by VIA could save their lives; cervical cancer was a concern for 98.6 %; and only 11.6 % felt anxious about repeating the VIA test. The majority of women (98.6 %) were satisfied with the service received at the health center.

Conclusions

This study showed that the participants had a strong perception about cervical cancer screening and were willing to have further confirmation or future retests.

Full article at:   http://goo.gl/Gi0ZWD

By:  Farida Selmouni^12*, Ahmed Zidouh³, Consuelo Alvarez-Plaza¹ and Karima El Rhazi⁴

¹Complutense University of Madrid, Madrid, Spain

²Higher Institute of Nursing Professions and Techniques of Health of Rabat, Rabat, Morocco

³Lalla Salma Foundation, Cancer Prevention and Treatment, Rabat, Morocco

⁴Laboratory of Epidemiology, Clinical Research and Community Health, Sidi Mohamed Ben AbdIllah University, Fez, Morocco

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Human Immunodeficiency Virus & Viral Hepatitis among High-Risk Groups: Understanding the Knowledge Gap in the Middle East & North Africa Region

To identify gaps in the existing knowledge on single, dual and triple infections of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) in the Middle East and North Africa (MENA) region among men who have sex with men (MSMs), female sex workers (FSWs), injecting drug users (IDUs) and prisoners.

We performed an extensive literature search on articles published on the topic in the 25 countries of the MENA region. PubMed database was used as the main search engine. Case reports, case series, qualitative studies, editorials, commentaries, authors’ replies and animal studies were excluded. Original articles and reviews dealing with the prevalence of HIV, HBV and HCV and their co-infection were included. Data on population type, sample size, age and markers of infections were extracted from the relevant studies.

HIV, HBV and HCV are blood-borne viruses with similar modes of transmission. The categories of people at high risk of acquiring HIV-1, HBV and HCV commonly include: MSMs, FSW and IDUs. It is well established that HIV-positive individuals co-infected with HBV or HCV suffer from liver pathology associated with morbidity and mortality. Moreover, HIV-infected individuals do not respond well to treatment for HBV or HCV and hence are at increased risk of hepatic toxicity. Consequently, co-infection of HIV-positive individuals with HBV and/or HCV is a global health problem of significant magnitude. Our review reveals the paucity of epidemiological data for key populations in many countries of the region. Limited number of studies exists in the MENA region on the status of HIV, HBV and HCV and their co-infections among prisoners, MSMs and FSWs. Evidence support the continued increase of the HIV epidemic among MSMs. In addition to the lack of studies on MSMs and FSWs in the MENA region, our review highlights the lack of data on the practices, characteristics, or the status of HIV infection and viral hepatitis among male sex workers selling or exchanging sex for money.

The MENA countries are in urgent need of advanced research and strengthening of the data collection systems and reporting practices of these infections among key populations.

Table 1

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among prisoners from Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
Egypt	500	41.0	0.0	9.8	15.8	0.0	0.0	0.0	[14]
Iran	160	16.6	0.6	0.6	NS	0.0	NS	NS	[15]
	392a	35.9	17.0	4.5	80.5	0.8	14.5	0.8	[16]
	358b	34.7	0.0	6.1	8.1	0.0	0.0	0.0	[17]
	163	34.5	0.0	7.4	7.4	0.0	0.0	0.0	[18]
	249a	35.4	15.1	4.7	64.8	1.1	14.3	1.1	[19]
	150a	31.4	42.5	18.9	75.9	NR	NR	NR	[20]
Lebanon	580	31.7	0.2	2.4	3.4	0.0	0.0	0.0	[21]
Libya	6371	> 16	18.2	6.9	23.7	NR	NR	1.5	[22]

aAmong prisoners who inject drugs;

bDrug-related convictions; n: Sample size; NR: Not reported; NS: Not studied. All numbers were rounded to the nearest 1. HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 2

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among female sex workers and men who have sex with men in Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
FSWs
Lebanon	103a	≥ 18	0.0	0.0	0.0	0.0	0.0	0.0	[23]
Libya	69a	≥ 15	10.1	2.9	7.2	0.0	4.3	0.0	[24]
Turkey	130	38.9	0.0	3.1	0.8	0.0	0.0	0.0	[25]
MSM
Lebanon	101a	≥ 18	1.0	1.0	0.0	0.0	0.0	0.0	[23]
Libya	227a	≥ 15	5.3	3.1	8.4	0.0	4.4	0.0	[24]

aNon-adjusted prevalence using respondent-driven sampling method. All numbers were rounded to the nearest 1. HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 3

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among injecting drug users in Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
Cyprus	40	25-31	0.0	0.0	50.0	0.0	0.0	0.0	[27]
Iran	202	-	NR	NS	52.0	NS	9.4	NS	[28]
	417	≥ 17	24.4	NS	80.0	NS	24.0	NS	[29]
	258	28.8	18.8	NS	65.9	NS	NR	NS	[30]
	233	32.3	7.7	22.7	40.3	4.7	6.4	4.7	[31]
	117a	< 30	0.7	0.7	59.0	0.0	0.0	0.0	[32]
	899	33.9	10.7	50.7	34.5	7.8	8.7	6.5	[33]
	100	17-58	19.0	6.0	56.0	NR	15.0	5.0	[34]
	268	37.0	10.8	6.0	39.2	NR	NR	NR	[35]
	153	30.7	5.9	22.9	59.5	2.0	5.2	1.3	[36]
	539	35.3	NR	NR	NR	0.0	1.1	NR	[37]
	200	36.5	1.5	4.5	12.0	0.0	0.0	0.0	[38]
	1327	26.5	20.2	NS	13.5	NS	NR	NS	[39]
	518	35.2	15.5	3.7	69.5	0.6	11.2	0.6	[16]
Israel	743	33.8	1.9	8.6	69.3	NR	NR	NR	[40]
Lebanon	106a	≥ 18	0.9	2.8	52.8	0.0	0.0	0.0	[44]
Libya	328a	≥ 15	87.1	4.5	94.2	4.2	83.2	NR	[41]
Palestine	192	41.3	0.0	2.6	43.8	0.0	0.0	0.0	[42]
Saudi Arabia	297	31.0	0.7	6.1	37.7	NR	NR	NR	[43]

aEstimated prevalence using respondent-driven sampling method. All numbers were rounded to the nearest 1. n: Sample size; NR: Not reported; NS: Not studied; HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 4

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among different populations from Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
HIV infected individuals
Iran	64	-	-	-	-	18.8	NS	NS	[49]
	168	38.7	-	-	-	NS	87.5	NS	[50]
	1338	32-42	-	-	-	NS	78.0	NS	[51]
	106	36.6	-	-	-	20.8	67.0	NR	[52]
	80	37.0	-	-	-	11.3	33.8	25.0	[53]
	130	50.2	-	-	-	11.5	77.0	9.2	[54]
	391	-	-	-	-	14.5	72.0	7.9	[55]
	201	36.0	-	-	-	44.3	67.2	36.3	[56]
	1444	38.4	-	-	-	NS	78.4	NS	[57]
Morocco	503	39.0	-	-	-	29.4	5.4	NR	[58]
Sudan	358	35.0	-	-	-	26.8	NS	NS	[59]
Turkey	949	37.9	-	-	-	0.0	0.9	0.0	[60]
Blood donors
Cyprus	5057	34.5	0.0	3.0	0.5	0.0	0.0	0.0	[61]
Iran	6499851	-	< 0.1	0.6	0.1	NR	NR	NR	[62]
	2026628	38.0	< 0.1	0.4	0.1	NR	NR	NR	[63]
UAE	592	-	1.2	67.2	31.6	NR	NR	NR	[64]
Others
Cyprus
Soldiers	12488	34.5	0.0	2.2	0.5	0.0	0.0	0.0	[61]
Iran
HBV patients	264	41.6	0.4	-	4.5	0.4	NR	NR	[65]
HIV infected patients’ partners	168	33.2	NR	NS	NR	NS	9.5	NS	[50]
Non-injecting drug users	336	28.5	1.5	5.6	4.5	1.2	0.9	0.9	[31]
Referral from behavioral counseling center	379	29.7	4.0	2.9	35.6	0.8	3.4	0.3	[66]
Libya
General Population	9170	34.0	0.2	3.7	0.9	< 0.1	0.1	< 0.1	[67]
Medical waste handlers	300	-	0.0	2.3	2.7	0.0	0.0	0.0	[68]
Non-Medical waste handlers	300	-	0.0	0.3	0.0	0.0	0.0	0.0	[68]
Turkey
ER patients	1000	51.7	0.0	5.0	1.8	0.0	0.0	0.0	[69]
In and out-patients	97000-225000	-	0.3	33.9	1.2	NR	NR	NR	[70]

All number were rounded to the nearest 1. n: Sample size; NR: Not reported; NS: Not studied; HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Full article at:  http://goo.gl/FW5TbL

  

By:  Nada M Melhem, Nour Rahhal, Rana Charide, Khalil Kreidieh, and Rolla El-Khatib

Nada M Melhem, Khalil Kreidieh, Rolla El-Khatib, Medical Laboratory Sciences Program, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon

Nour Rahhal, Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon

Rana Charide, Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon

Author contributions: Melhem NM designed and wrote the paper; Rahhal N, Charide R and Kreidieh K reviewed the literature, prepared the tables and contributed to the write-up; El-Khatib R critically read the manuscript.

Correspondence to: Nada M Melhem, PhD, Assistant Professor of Infectious Diseases, Medical Laboratory Sciences Program, Faculty of Health Sciences, American University of Beirut, 325 Van Dyck Hall, 11-0236 Riad El Solh, Beirut 1107-2020, Lebanon. bl.ude.bua@nmehlem

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